The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes. Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes. Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses' station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement. Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of 'increased postoperative surveillance' during the ASOS-2 Trial

Effect of swamp cultivation on distribution of anopheline larval habitats in Western Kenya.

Background & objectives: Malaria resurgence in highland regions of East Africa has been on increase. The spatio-temporal distribution of larval habitats of malaria vectors determines the distribution of adult vectors, hence, disease transmission. Vector’s ecology is necessary for strategic vector control through effective plan for source reduction. Mapping of the larval habitats is necessary for targeted control measures. The purpose of this study is to assess and compare the spatial and seasonal variations in anopheline larval habitats in Western Kenya. Methods: A comparative study was conducted on spatial distribution of GPS geo-located anopheline larval habitats in relation to highland and lowland environments. Land use types were categorized and all potential aquatic habitats of malaria vectors were examined in February, May, August and November 2004. Data analyses were performed using SAS JMP software. Results & discussion: Results showed a higher percentage of Anopheles gambiae s.s. (70.9%) than An. funestus (29.1%) in highland. In the lowland, An. gambiae s.l. comprised 60.1% while An. funestus represented 39.9%. The distribution of larval breeding is confined to the valley bottom in the highland while it was dispersed in the lowland. Land use type influenced the occurrence of positive breeding habitats in the highland. In the lowland, distribution was due to seasonality. We found high proportion of potential and positive breeding sites in cultivated swamps and farmlands at the highland site. These results suggest that swamp cultivation increases the availability and suitability of larval breeding habitats of malaria vectors, thus malaria transmission in the Western Kenya highlands environment.